From the Guidelines
Pulmonary embolism (PE) often presents with nonspecific physical exam findings, but common signs include tachycardia, tachypnea, and hypoxemia, as well as signs of right heart strain such as hypotension, elevated jugular venous pressure, and a loud P2 heart sound 1. The physical exam findings associated with PE can be varied and may include:
- Tachycardia (heart rate >100 beats per minute)
- Tachypnea (respiratory rate >20 breaths per minute)
- Hypoxemia (oxygen saturation <95% on room air)
- Signs of lower extremity deep vein thrombosis such as unilateral leg swelling, warmth, erythema, or tenderness
- Pleuritic chest pain may be elicited on palpation of the affected area
- Wheezing, rales, or decreased breath sounds might be heard on lung auscultation, though these findings are variable
- In severe cases, patients might present with hypotension, elevated jugular venous pressure, a loud P2 heart sound, or a right-sided S3 gallop indicating right heart strain
- Cyanosis, diaphoresis, and altered mental status can occur in massive PE due to hemodynamic compromise 1. It's essential to note that many patients with confirmed PE have minimal or no physical exam abnormalities, which is why clinical suspicion based on risk factors and symptoms, combined with appropriate diagnostic testing, is crucial for diagnosis rather than relying solely on physical examination. The diagnosis of acute pulmonary embolism is challenging, and echocardiography can help establish a prompt diagnosis and identify patients with high-risk features, although its sensitivity is about 50–60% and specificity is around 80–90% 1. In patients with a relevant history and clinical findings, a ratio between end-diastolic RV to LV can be an indirect finding for pulmonary embolism, indicating acutely increased pulmonary artery/right heart pressures 1.
From the Research
Physical Exam Findings in Pulmonary Embolism
The physical exam findings associated with pulmonary embolism (PE) can vary, but some common signs and symptoms have been identified in various studies 2, 3, 4. These include:
- Dyspnea (shortness of breath) in 70-90% of patients 2, 3, 4
- Tachypnea (rapid breathing rate) in 28-85% of patients 2, 3, 4
- Tachycardia (rapid heart rate) in 28-58% of patients 2, 3, 4
- Pleuritic pain (chest pain that worsens with deep breathing) in 38-74% of patients 2, 3, 4
- Hypoxemia (low oxygen levels in the blood) in 71% of patients 2
- Accentuated pulmonary component of the second heart sound in 57% of patients 3
- Rales (crackles in the lungs) in 56% of patients 3
- Signs of deep venous thrombosis in 41% of patients 3
- Pleural friction rub in 18% of patients 3
Vital Signs and Laboratory Findings
In addition to physical exam findings, vital signs and laboratory results can also be abnormal in patients with PE. These include:
- Low oxygen saturation 5
- Hypotension (low blood pressure) in 22% of patients 2
- Elevated troponin and BNP levels 5
- Elevated fibrinogen levels 5
- Abnormal arterial blood gases, including low PaO2 and high alveolar-arterial oxygen gradient 2, 4
Clinical Scoring Systems
Clinical scoring systems, such as the Wells and Geneva scores, can be used to estimate the probability of PE and guide further diagnostic testing 5. The Wells scoring system was found to be more successful than other scoring systems in one study 5.